ReQoL/10 PHB Outcome measure

PHB Outcome measure - ReQoL/10
Recovery goals/PHB Outcome
Referrer name

First NameLast Name
Borough
Email address
example@example.com
Review date

DayMonthYear
Date
PHB holder name

First NameLast Name
PHB package number
NHS number
Impact on Support
Over the PHB 3 month period:
Has the PHB holder been admitted as an inpatient during this 3 month PHB period?
Has the PHB holder had any crisis / unplanned meetings or interventions during this 3 month PHB period?
Has the PHB holder reduced care team / clinical support or need?
Has the PHB holder been discharged from referrer care or is ready to be?
In your own words, what changes/ impact has this PHB had in care and support/ improvements to MH?
Please tell us how much you agree or disagree with this statement:
"The Personal Health Budget has supported me to work towards my mental health recovery goal"*
Please tell us a little more about why you have selected the answer above*
Do you have further recovery goals you would like to be supported with
Please detail
Additional information
Is there anything else you wish to share about your Personal Health Budget experience?
What if anything, would have made your PHB experience better or improved?
ReQoL/10 monitoring
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I found it difficult to get started with everyday tasks
Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I felt able to trust others
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I felt unable to cope
Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I could do the things I wanted to do
I felt happy
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I thought my life was not worth living
Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I enjoyed what I did
I felt hopeful about my future
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I felt lonely
I felt confident in myself
Experience of the Personal Health Budget (optional)
Please tell us how much you agree or disagree with the following statements:
"I would recommend this service"*
"I was able to get what I needed to support my mental health recovery goal"*
"I felt I had choice and control over my recovery plan"*
"I benefited from what my personal health budget enabled me to do"*
Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
Should be Empty:

PHB Outcome measure - ReQoL/10

Recovery goals/PHB Outcome

Impact on Support

Additional information

ReQoL/10 monitoring

Experience of the Personal Health Budget (optional)